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Year : 2022  |  Volume : 3  |  Issue : 3  |  Page : 76-80

Knowledge, attitude, and practices pertaining to COVID-19 among pregnant women: A cross-sectional study

Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

Date of Submission30-Jan-2022
Date of Decision20-Feb-2022
Date of Acceptance22-Feb-2022
Date of Web Publication14-Sep-2022

Correspondence Address:
Dr. Pallabi Nayak
Plot No - 67, Bapujinagar, Bhubaneswar - 751 009, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jphpc.jphpc_6_22

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Background: Since its emergence in 2019, COVID-19 has affected all groups of people across several countries. Updated information about the disease and its application is the key to halt the spread of infection. Although there have been widespread awareness campaigns on COVID-19, the level of awareness among vulnerable groups such as pregnant women needs to be evaluated. Aims: The aim of this study was to assess the level of knowledge, attitude, and practices toward COVID-19 among pregnant women and its association with various demographic variables. Subjects and Methods: This was a cross-sectional descriptive study conducted between July 1, 2020, and September 30, 2020. Assessment was done using a self-designed questionnaire. Participants scoring more than 50% marks in each section were considered to have adequate knowledge, positive attitude, and good practice. Statistical analysis was done using SPSS version 20. Results: The total number of pregnant women included was 244. About 59% of women had adequate knowledge about COVID transmission and protective measures. All women had a positive attitude toward preventive measures taken by the government. About 98% of women agreed that all preventive measures taken by the government were beneficial. Almost all (98%) women had good practice of safety measures such as social distancing, wearing masks, and frequent handwashing. However, no association was observed between demographic variables and level of knowledge, attitude, or practice. Conclusion: The study showed adequate knowledge and good practice by most pregnant women irrespective of their level of education and socioeconomic status. Targeted health education to pregnant women can further ensure safe practices during pregnancy.

Keywords: Attitude, COVID-19, knowledge, practice, pregnancy

How to cite this article:
Nayak P, Rath A, Mitra S, Begum J. Knowledge, attitude, and practices pertaining to COVID-19 among pregnant women: A cross-sectional study. J Public Health Prim Care 2022;3:76-80

How to cite this URL:
Nayak P, Rath A, Mitra S, Begum J. Knowledge, attitude, and practices pertaining to COVID-19 among pregnant women: A cross-sectional study. J Public Health Prim Care [serial online] 2022 [cited 2023 Feb 6];3:76-80. Available from: http://www.jphpc.org/text.asp?2022/3/3/76/354821

  Introduction Top

Novel coronavirus severe acute respiratory syndrome coronavirus (SARS-COV-2) is a new strain of coronavirus causing COVID19, the current pandemic.[1] Although pregnant women are not necessarily more susceptible to viral illness, changes to their immune system in pregnancy can be associated with more severe symptoms. About two-third of pregnant women infected by COVID 19 are asymptomatic. Most symptomatic women experience only mild or moderate cold/flu-like symptoms.[2] However, compared to nonpregnant women, pregnant women with COVID 19 have higher rates of intensive care unit (ICU) admission. In the past, SARS-CoV and Middle East respiratory syndrome-CoV were both responsible for severe complications during pregnancy, including the need for endotracheal intubation, admission to an ICU, renal failure, and death.[3],[4],[5] As observed during SARS 2003, lack of proper knowledge and attitude toward control of infectious diseases can jeopardize the efforts for control of the disease.[6],[7]

Extraordinary public health and infection control measures are being carried out all over the world to contain the infection. Knowledge and awareness regarding the mode of disease transmission, basic hand hygiene principles, and measures for social distancing are vitally important for developing effective control measures. With a female literacy rate of 64.01% and most women belonging to impoverished families in India, it is important to identify knowledge gaps, cultural beliefs, or behavioral patterns that may facilitate health professionals to spread awareness and information regarding personal as well as community prevention measures.

The objective of our study was to assess the knowledge, attitude, and practices (KAP) of pregnant women toward COVID19 and their association with demographic variables.

  Subjects and Methods Top

Our study was a cross-sectional descriptive study. It was conducted between July 1, 2020, and September 30, 2020, in the department of obstetrics and gynecology. All pregnant women fulfilling the selection criteria in outdoor, indoor ward, and labor room were included in the study. Patients with severe morbidities such as severe preeclampsia/eclampsia, heart disease in failure, antepartum hemorrhage, unstable hemodynamic conditions, those requiring intensive care support, and those who were not in a condition to respond to the questionnaire were excluded from the study. Verbal consent was obtained from each participant. Data collection was started after ethical approval by the research committee of the institute.

Assessment was done using a self-designed questionnaire. The questionnaire included 13 questions on sociodemographic data of pregnant women, 10 questions on knowledge, 9 questions on attitude, and 6 questions on practices pertaining to COVID-19. The total number of responses in the KAP sections were 26, 26, and 16, respectively. The questionnaire was pretested among 10 pregnant women. The responses in the knowledge and attitude section were in the form of YES/NO or NOT SURE. Some of the responses in the knowledge section were to choose an appropriate answer among all options. Each correct answer carried one mark and each incorrect or not sure response carried a zero mark. The responses in the practice section were assessed by a Likert scale of 3 (0–2). All the responses were marked by the interviewer (PI/CO PI) in the tick boxes. The highest score was 26 for both knowledge and attitude sections, whereas for the practice section, it was 38. Participants scoring more than 50% marks in each section were considered to have adequate knowledge, positive attitude, and good practice, respectively.

Statistical analysis was done using SPSS version 20 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp). Categorical and continuous variables data were expressed as percentages and mean or median, respectively. Pearson's Chi-square test was used for testing the association of demographic variables with KAP score. Odds ratio and 95% confidence interval were calculated. P < 0.05 was considered statistically significant.

  Results Top

The total number of pregnant women included in our study was 244 with ages ranging from 18 years to 50 years. Most of our study population was from urban residence (56.6%). Most women (95.9%) were Hindus and the rest (4.1%) belonged to Islam religion. Majority of the women had a good education; 38.1% were educated up to graduation or higher followed by 29.1% higher secondary and 25.4% secondary schooling. Out of the 244 respondents, only 16.8% were employed. We used the modified Kuppuswamy Scale to classify our women into five classes of socioeconomic status. Upper middle class was the predominant socioeconomic class (76.6%), followed by the lower middle class (14.3%). [Table 1] depicts all the demographic characteristics of our study population.
Table 1: Distribution of demographic variables

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More than half of the women (59.8%) were nulliparous. Similarly, around half of the respondents (50.8%) had a term gestation of 37–42 weeks. Only seven out of 244 women had known or suspected cases of COVID-19 in the neighborhood or at home. Two women had recent travel history to COVID-affected areas. [Table 2] shows the total scores in KAP section.
Table 2: Knowledge, attitude, and practice scores

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More than half participants (59.8%) had adequate knowledge about COVID transmission and protective measures. Out of all, 97.5% of women knew at least one mode of transmission and 98.4% women knew at least one symptom of COVID. Majority of women (78.7%) were aware of social distancing as a measure for prevention of transmission. No significant association was found between knowledge and demographic variables.

All women in our study had a positive attitude toward preventive measures taken by government and health-care facilities. About 98% of women agreed that all preventive measures taken by the government were beneficial. Majority (83.6%) of women stated that they would self-isolate themselves if they develop symptoms of COVID. Three out of all women stated that they would choose cesarean section as the mode of delivery if they are infected. About 37% of women stated that breastfeeding should be avoided by COVID-positive mothers. There was no association found between attitude and any of the demographic variables.

Almost all (98%) women had good practice of safety measures such as social distancing, wearing masks, frequent handwashing, avoiding public transport and social gatherings, and disinfecting households. Best practice, i.e., that is following all these measures, was implemented by 38.1% of women. However, no association was observed between practice and demographic variables. [Table 3] demonstrates the association between KAP scores and demographic variables.
Table 3: Association with demographic variables and obstetric factors

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  Discussion Top

Since the emergence of novel coronavirus disease, there have been constant efforts to understand its clinical course and effects on human body. Pregnancy being a vulnerable state has led to more attention on research on its effect on both mother and fetus. Various preventive measures have been recommended by the WHO and other health organizations. There have been widespread campaigns and spread of information by various media platforms. This has led to increased awareness among population. Similar to few other KAP studies, our study revealed adequate knowledge in more than half of pregnant women and good practice and attitude by most of the women.

Our study showed that 59.8% of women had adequate knowledge regarding the mode of transmission of coronavirus, symptoms, social distancing, quarantine, and other protective measures. Similar results were found in other studies such as Nwafor et al.(60.9%).[8] Another Indian study by Kamal et al. showed 75.3% of pregnant women had adequate knowledge.[9] This might be because, 83% of women in that study had graduate or higher level of education compared to 38% in our study. In our study, 70% of women correctly answered the minimum duration of handwashing to be 20 s. Most of them (93.4%) were aware of quarantine and 78.7% of women knew about physical distancing.

About 64% of women were aware of their increased susceptibility due to pregnancy. Increased susceptibility during pregnancy has also been observed in various studies. The United States Centers for Disease Control and Prevention published a large study in November 2020, which found that pregnant women were more likely to be admitted to ICU (adjusted risk ratio: 3.0) to receive invasive ventilation (aRR: 2.9), extracorporeal membrane oxygenation (aRR: 2.4), and to die (1.5 vs. 1.2/1000 cases; aRR 1.7).[10] A large case–control study from Mexico compared 5183 pregnant women with symptomatic COVID-19 with 5183 matched nonpregnant controls.[11] Pregnant women had higher odds of death (odds ratio [OR] 1.84, 95% confidence interval [CI] 1.30–2.61), pneumonia (OR: 1.99, 95% CI: 1.81–2.19), and ICU admission (OR: 2.25, 95% CI: 1.86–2.71) but similar odds of intubation (OR: 0.93, 95% CI: 0.70–1.25).

Many studies have also revealed possible adverse pregnancy outcomes due to COVID-19. In our study, only 25% of women believed that there is an increased chance of complications such as abortion, preterm birth, and fetal death if a mother is affected. About 61% of women had no knowledge regarding the possible effects of COVID on pregnancy. In other studies, such as Lee et al., 46% of women believed that they might go into preterm labor or miscarry if they are infected with COVID 19.[12] The updated UK Obstetric Surveillance System (study) found that preterm birth was more likely for women with COVID-19.[13] About 19% of women with symptomatic COVID-19 had preterm delivery compared to 9% of women with asymptomatic COVID-19. The PregCOV-19 Living Systematic Review concluded the risk of preterm birth at approximately 17%.[14] It also showed that there was no evidence of an increase in stillbirth or neonatal death among women with COVID-19, and insufficient evidence to comment on the risk of miscarriage. The possible explanation for lack of knowledge regarding the effects of COVID on pregnancy might be due to little available evidence at the time of our study which led to lesser dissemination of awareness regarding the same. Although information regarding the virus and its effects in the general population as well as in specialized populations such as old/immunocompromised people was spread diligently using the most basic and widespread media, it may be assumed that the same was not done for our pregnant population. Their only source of information regarding the management of COVID-19 in pregnancy and puerperium was health-care workers.

All women in our study showed a positive attitude toward preventive measures against COVID-19. Almost all pregnant women agreed that implementation of lockdown, mandatory use of face masks in public places, social distancing, handwashing, and maintaining cough etiquette have been beneficial. In addition to the implementation of strict measures by the government to contain the spread of infection, constant health education to pregnant women in OPD as well as via telemedicine has been successful in changing the attitude of pregnant women. More than 90% of women agreed that going to religious places, attending family functions, and unnecessary visits to marketplaces need to be avoided. However, 86% of women agreed that they must attend the hospital for antenatal checkups with appropriate precautionary measures. During the lockdown period, health-care workers all over the country have faced difficulty and discrimination in residential areas, as they were thought to be infection carriers. However, 87% of our participants agreed that health-care workers should not be denied to reside in the same neighborhood.

Majority of our respondents agreed to the basic measures required to be taken on developing symptoms, i.e., 83% of women said that they would self-isolate themselves and 97.1% agreed to attend specialized screening centers. More than 95% of women agreed that during self-isolation, they have to stay confined to one room and avoid public places and public transport. However, 30% of women wrongly believed that they can share utensils with family members during self-isolation.

In our study, only three out of 244 women (1.2%) expressed a preference for a cesarean delivery if they would be infected with COVID-19. This is in contrast to the study by Lee et al. wherein 53% of women would choose a cesarean section.[12] This difference might be due to the fact that most women in our study were booked patients and they had been counseled and educated repeatedly regarding the effects of COVID-19 on mother and fetus along with risks and benefits of cesarean delivery. According to a systematic review on the maternal transmission of SARS CoV 2 to the neonate, the rate of neonatal COVID-19 infection is no greater when babies are born vaginally.[15]

Poor knowledge regarding COVID-19 in pregnancy translated to a poor attitude toward breastfeeding practices, as only 45% of the respondents agreed to breastfed their babies if they got infected with COVID-19. However, after knowing that breastfeeding is not contraindicated, most of them (more than 95%) agreed to follow the precautions such as wearing a mask, washing hands before and after breastfeeding, covering their faces while coughing, and discarding used tissues properly. Hence, we focused on educating all pregnant mothers regarding breastfeeding with all safety measures. A cohort study demonstrated that both skin-to-skin contact and breastfeeding are not associated with increased neonatal infection with SARS-CoV-2.[16] According to UNICEF UK Baby Friendly Initiative, the benefits of breastfeeding outweigh any potential risks of transmission of the virus through breastmilk.[17] A good practice level was observed in almost all pregnant women of our study (98%). Nearly 90% of women avoided social gatherings and public transport, 77% of participants always wore masks while in public, and 70% practised frequent handwashing. Ninety-three percent (93%) always maintained social distancing. However, 16% of women avoided meat and dairy products due to their misconception regarding the mode of transmission. One out of 244 women took some prophylactic medication. For most women, the source of information was television followed by newspapers. About 74% of women continued healthy living habits such as regular exercise and a healthy diet during the pandemic. Best practice, i.e., following all the preventive measures, was done by 38% of the women.

Our study revealed adequate knowledge by more than half of the participants whereas positive attitude and good practice by almost all pregnant women. No association was found with any of the demographic variables. It suggests similar awareness levels and behavioral responses among all groups irrespective of their educational qualifications, employment status, or socio-economic strata. This could be attributed to the effective and intensive awareness campaigns and precautionary steps implemented by the government and continuous health education by health-care workers and other organizations.

Communication and mass education are crucial for preventive practices during a pandemic. Targeted health education to the vulnerable population such as pregnant women is also equally important. This can be achieved by the spread of awareness and demonstration of safe practices not only by health-care workers but also by various media platforms. Primary care physicians should educate pregnant women regarding the spread of the disease, precautionary measures, especially benefits of vaccination at each visit.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3]


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